Provider Demographics
NPI:1538150131
Name:EDMUNDS, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:EDMUNDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:973 MICA DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89705-7255
Mailing Address - Country:US
Mailing Address - Phone:775-783-6190
Mailing Address - Fax:775-783-6191
Practice Address - Street 1:973 MICA DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89705-7255
Practice Address - Country:US
Practice Address - Phone:775-783-6190
Practice Address - Fax:775-783-6191
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6786207X00000X
CAG75392207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV200026572OtherMEDICARE RAILROAD
NV002013131Medicaid
NVCC7065OtherBCBS
NVCC7065OtherBCBS
NVVWQBCT07Medicare PIN